Diagnosis and Management

of Shock

dr. Rudi, Sp.An
SHK 1

Objectives
Identify the major types of shock and principles of
management
Review fluid resuscitation and use of vasopressor and
inotropic agents
Understand concepts of O
2
supply and demand
Discuss the differential diagnosis of oliguria
SHK 2

Shock
Always a symptom of primary cause
Inadequate blood flow to meet tissue oxygen
demand
May be associated with hypotension
Associated with signs of hypoperfusion: mental
status change, oliguria, acidosis
SHK 3

Shock Categories
Cardiogenic
Hypovolemic
Distributive
Obstructive
SHK 4

Cardiogenic Shock
Decreased contractility
Increased filling pressures, decreased LV
stroke work, decreased cardiac output
Increased systemic
vascular resistance compensatory
Hypovolemic Shock
Decreased cardiac output
Decreased filling pressures
Compensatory increase in
systemic vascular resistance
SHK 6

Distributive Shock
Normal or increased cardiac output
Low systemic vascular resistance
Low to normal filling pressures
Sepsis, anaphylaxis, neurogenic,
and acute adrenal insufficiency
SHK 7

Obstructive Shock
Decreased cardiac output
Increased systemic vascular
resistance
Variable filling pressures dependent
on etiology
Cardiac tamponade, tension
pneumothorax, massive pulmonary
embolus
Cardiogenic Shock Management
Treat arrhythmias
Diastolic dysfunction may require
increased filling pressures
Vasodilators if not hypotensive
Inotrope administration
Cardiogenic Shock Management
Vasopressor agent needed if
hypotension present to raise aortic
diastolic pressure
Consultation for mechanical assist
device
Preload and afterload reduction to
improve hypoxemia if blood pressure
adequate

Hypovolemic Shock
Management
Volume resuscitation crystalloid, colloid
Initial crystalloid choices
Lactated Ringers solution
Normal saline (high chloride may produce
hyperchloremic acidosis)
Match fluid given to fluid lost
Blood, crystalloid, colloid

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Distributive Shock Therapy
Restore intravascular volume
Hypotension despite volume therapy
Inotropes and/or vasopressors
Vasopressors for MAP < 60 mm Hg
Adjunctive interventions dependent on
etiology
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Obstructive Shock Treatment
Relieve obstruction
Pericardiocentesis
Tube thoracostomy
Treat pulmonary embolus
Temporary benefit from fluid or
inotrope administration
Fluid Therapy
Crystalloids
Lactated Ringers solution
Normal saline
Colloids
Hetastarch
Albumin
Gelatins
Packed red blood cells
Infuse to physiologic endpoints

SHK 14

Fluid Therapy
Correct hypotension first
Decrease heart rate
Correct hypoperfusion abnormalities
Monitor for deterioration of oxygenation
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Inotropic / Vasopressor Agents
Dopamine
Low dose (2-3 g/kg/min) mild inotrope
plus renal effect
Intermediate dose (4-10 g/kg/min)
inotropic effect
High dose ( >10 g/kg/min) vasoconstriction
Chronotropic effect
SHK 16

Inotropic Agents
Dobutamine
5-20 g/kg/min
Inotropic and variable chronotropic effects
Decrease in systemic vascular resistance
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Inotropic / Vasopressor Agents
Norepinephrine
0.05 g/kg/min and titrate to effect
Inotropic and vasopressor effects
Potent vasopressor at high doses
SHK 18

Inotropic / Vasopressor Agents
Epinephrine
Both and actions for inotropic and
vasopressor effects
0.1 g/kg/min and titrate
Increases myocardial O
2
consumption
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Therapeutic Goals in Shock
Increase O
2
delivery
Optimize O
2
content of blood
Improve cardiac output and
blood pressure
Match systemic O
2
needs with O
2
delivery
Reverse/prevent organ hypoperfusion

Oliguria
Marker of hypoperfusion
Urine output in adults
<0.5 mL/kg/hr for >2 hrs
Etiologies
Prerenal
Renal
Postrenal
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Evaluation of Oliguria
History and physical examination
Laboratory evaluation
Urine sodium
Urine osmolality or specific gravity
BUN, creatinine
SHK 22

Evaluation of Oliguria
Laboratory Test Prerenal ATN
Blood Urea Nitrogen/ >20 1020
Creatinine Ratio
Urine Specific Gravity >1.020 <1.010
Urine Osmolality (mOsm/L) >500 <350
Urinary Sodium (mEq/L) <20 >40
Fractional Excretion of Sodium (%) <1 >2
Therapy in Acute Renal Insufficiency
Correct underlying cause
Monitor urine output
Assure euvolemia
Diuretics not therapeutic
Low-dose dopamine may urine flow
Adjust dosages of other drugs
Monitor electrolytes, BUN, creatinine
Consider dialysis or hemofiltration
SHK 24

Pediatric Considerations
BP not good indication of hypoperfusion
Capillary refill, extremity temperature better
signs of poor systemic perfusion
Epinephrine preferable to norepinephrine due to more
chronotropic benefit
Fluid boluses of 20 mL/kg titrated to BP or total 60
mL/kg, before inotropes or vasopressors
SHK 25

Pediatric Considerations
Neonates consider congenital
obstructive left heart syndrome as cause of
obstructive shock
Oliguria
<2 yrs old, urine volume <2 mL/kg/hr
Older children, urine volume
<1 mL/kg/hr
SHK 26